MRCGP exam update: Secondary stroke prevention

After either a TIA or a minor stroke the risk of future stroke becomes 8-12 per cent at seven days, and 11-15 per cent at one month (BMJ 2004; 328: 326)

Much of the responsibility for delivering effective secondary prevention and managing longer term problems associated with stroke falls to the primary care team.

Overall GP care of stroke patients has improved since April 2004, according to an analysis of GMS quality framework data on stroke in the National Audit Office report ‘Reducing brain damage: faster access to better stroke care'.

Older patients and those with more severe disability after stroke are less likely to receive appropriate secondary prevention (Age and Ageing 2004; 33: 280).

What is the evidence?

Combining antiplatelet drugs may not be beneficial. In one study patients who had a recent stroke or TIA were randomised to receive a combination of either aspirin with placebo or aspirin with clopidogrel (Lancet 2004; 364: 331). The results showed that the risk of major bleeding with the additional of aspirin outweighs any benefit at 18 months.

In a randomised controlled trial involving 320 patients with a history of aspirin-induced ulcer bleeding, fewer patients had a further incidence of bleeding with aspirin plus esomeprazole than with clopidogrel alone (N Engl J Med 2005; 352: 238). Adding a proton pump inhibitor (PPI) to aspirin may be a preferable option to replacing aspirin with clopidogrel.

However, a large trial has found that the combination of aspirin and dipyridamole works better than aspirin alone (Lancet 2006; 367: 1,665). The two antiplatelet agents caused no more serious bleeding than aspirin alone.

Taken together, the current evidence supports a modest protective effect of folic acid against stroke by reducing homocysteine levels (BMJ 2006; 333: 1,114).

A recent study showed stroke (and TIA) in elderly patients are often under-investigated, which then results in under-treatment (BMJ 2006; 333: 525).

Implications for practice

All GPs should keep a register of stroke patients and conduct a regular audit of secondary prevention (specified in the new GMS contract).

In patients who have had strokes, statins reduce the incidence of coronary events, but it is not yet proven if statins reduce the incidence of recurrent strokes (Clin Exp Hypertens 2006; 28: 335).

Available guidelines

Primary Care Concise Guidelines for Stroke 2004. Royal College of Physicians, London.

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